At the age of 78, Maxine was a poster girl for
an active senior lifestyle. She loved being the
unofficial social director of her assisted
living community in the Texas Hill Country,
organizing shopping trips to San Antonio and
calling the numbers at the daily bingo game. Physically, Maxine was in great shape. She took a
brisk walk every morning and had a regular annual
physical exam. Her only chronic health problem was mild
Parkinson’s, which she controls with daily medication.
Maxine especially enjoyed sitting with her special
friends at dinner, she was very concerned when she began
to experience prolonged coughing fits at the table. At first she thought the problem might be simply
trying to talk, eat, and breathe at the same time – so
she decided to listen more and speak less. Things got
better for a while, though her friends did notice how
quiet and subdued she seemed.
Eventually, Maxine began to skip going to dinner and ate
in her room instead. She also began to have difficulty swallowing her
medication and vitamins. Sometimes she needed a whole
glass of water to get them down. Worried, she began to
have trouble going to sleep, which made her look tired. This change was very apparent to Maxine’s
daughter when she came to visit from out-of-state.
Maxine had always been so upbeat and positive. Now, for
the first time, she seemed confused and depressed.
What we don’t know can hurt us.
Dysphagia is the medical term for difficulty or
inability to swallow. Although it’s rarely talked
about, dysphagia can have an immediate negative
impact on quality of life. Eating, after all, is a
pleasurable group activity. A good meal satisfies
more than just the appetite. This may be especially
true for residents of independent or assisted living
communities, for whom mealtimes are a highlight of
the day. Beyond the social issues, dysphagia can
also have serious health-related consequences,
including malnutrition, dehydration, and aspiration
difficulties in swallowing are not a natural result
of aging. They are treatable and preventable, with
recognition of the problem as the first step.
However, there is evidence that dysphagia is often
undiagnosed or untreated: a recent study in Los
Angeles County found incidence of swallowing issues
in approximately 11 percent of seniors in assisted
or independent living facilities. Administrators in
these facilities confirm that residents’ swallowing
disorders are often unnoticed until the condition
has become fully established. At that point, a
feeding tube may become necessary. As a result, the
resident may need to be transferred to a skilled
care environment where appropriate support can be
provided. Ignored or unidentified, dysphagia can
lead to a basic loss of independence and
Recognition, Education, Control
Dysphagia has a variety of causes and can manifest
in a variety of ways. To identify the problem, the
right questions need to be asked in easily
understood language. It may also be necessary to
eliminate some common myths and misunderstandings.
Education, therefore, is a key element in bringing
dysphagia under control. This can begin with an
understanding of the swallowing process itself.
Picture A, a
morsel of food has been chewed and is ready to enter
food then pushed toward the back part of the mouth,
against the muscles of the pharyngeal wall as seen
in Pictures B and
Pictures D and
E, the airway
lifts and closes off when the soft pallet closes,
protecting the entrance to the nose. Then the
entrance to the esophagus opens, allowing food to
bypass the airway and enter the esophagus.
Finally, in Picture F
the food passes down the esophagus. The airways
reopen to allow continued breathing.
this sequence is disrupted at any point, dysphagia
can result. Because individuals may seek to avoid
the embarrassment of coughing or choking during
meals, they isolate themselves to the extent that
early signs go unrecognized. In making the
diagnosis, it’s important to be aware of conditions
such as Parkinson’s or gastro-esophageal reflux
(GERD), which can heighten vulnerability. Dysphagia
may also arise as a side effect of medication often
used for arthritis, Parkinson’s disease, depression
and other common conditions.
While it’s important to educate care providers about
dysphagia, it’s also crucial that seniors themselves
learn to recognize symptoms and seek treatment. For this to happen, a number of longstanding
barriers need to be overcome:
people with symptoms of dysphagia fail to report
them to physicians or caregivers, often to avoid
embarrassment. They may fear loss of independence,
or reduced enjoyment from meals.
In its early
stages, individuals may be unaware of the signs and
symptoms of dysphagia, or may choose to ignore them.
Dysphagia may be
seen as a “normal” part of the aging process.
person may be unaware of the mechanics of swallowing
and of safe swallowing strategies.
Individuals may not realize that there is a clinical
specialty dealing with swallowing problems, and that
help is readily available.
importantly, people may see swallowing issues as
insignificant, and remain unaware of the potential
The Happy Ending
her daughter’s help, Maxine’s story began to turn
Her daughter arranged for Maxine to visit her
primary care physician, who referred Maxine to a
speech and language pathologist in the outpatient
department of a local medical center. Janice, the SLP, asked Maxine about her
medical history and her current medical status. Then Janice performed a “tabletop clinical
evaluation,” examining Maxine’s facial and throat
muscle strength, and watching her swallow measured
amounts of water, pudding, and Lorna Doone cookies. This wasn’t at all an unpleasant or
threatening experience. In fact, Maxine began to
feel better right away because Janice assured her
that there were definitely ways to improve her
swallowing even if she were found to have a
Janice recommended that Maxine’s doctor refer her to
the medical center’s radiology department for an
x-ray procedure called modified barium swallow, or
MBS. Maxine was impressed by the fact that the
radiologist would watch her swallowing in real time
and could see exactly where she was having a problem
- but she was also apprehensive about having to
swallow the small amount of barium. But it turned out to be no problem, and no
more uncomfortable than the “tabletop clinical
evaluation,” and Janice was with her the whole time.
it turned out, Maxine did have dysphagia, probably
brought on by her Parkinson’s. But by identifying
the problem early, she was able to improve her
swallowing and go back to her busy social life. Janice taught her exercises to improve the
strength, range of motion, speed, and coordination
of her swallowing process. She also learned which
foods are most likely to cause choking. These can
vary from one person to another. In Maxine’s case
they included anything with vinegar and foods such
as watermelon that have both solid and liquid
consistency. While she will always need to be careful,
Maxine is back to her cheerful self, presiding over
meals and bingo games.
Take the Dysphagia Self Test
As with any medical
condition, early detection provides the greatest
number of treatment options for dysphagia. If
difficulty in swallowing begins to appear, the
problem should not be ignored and it should
certainly not be hidden. An appointment with a
physician should be made as soon as possible. In the
interval before the appointment, it can be useful to
keep a written record of when swallowing problems
occur and any changes in their frequency or
severity. Take the Dysphagia Self Test and bring your
results page with you to your doctor.
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